Flutamide-associated liver toxicity during treatment with total androgen suppression and radiation therapy for prostate cancer.

PURPOSE: To examine the frequency and severity of toxicity associated with flutamide inpatients treated with total androgen suppression before and during pelvic radiation therapy (RT) for prostate cancer. MATERIALS AND METHODS: Sixty-five patients with T2b-T4 prostate cancer received flutamide and goserelin acetate for 4 months, with RT beginning at the 3rd month. Treatment records including liver function test (LFT) results at baseline and during treatment were reviewed and toxicities noted. RESULTS: In 30 (46%) of 65 patients, flutamide was discontinued prematurely. Primary reasons included elevation in LFT levels (n=14); gastro-intestinal toxicity (n=9); decreased hemoglobin level (n=2); patient refusal (n=2); and arthralgia, rash, and malaise (n=1 each). Hepatotoxicity generally was manifest as asymptomatic transaminase level elevation. Grade 3-4 hepatotoxicity was noted in four of 65 patients. Mean aspartase aminotransferase increased from 23 (baseline) to 67 U/L (during flutamide treatment) (P<.02); mean alanine aminotransferase level increased from 26 (baseline) to 94 U/L (during flutamide treatment) (P<.005). CONCLUSION: Flutamide toxicity was common. LFTs should be monitored during flutamide therapy. The role of flutamide in this treatment regimen may need to be reevaluated.

Biologic response modifiers: therapeutic approaches to lymphoproliferative diseases.

Some biologic agents have proven effective in the treatment of lymphoproliferative diseases by stimulating host antitumor immunity or by applying active antitumor properties that specifically or nonspecifically effect tumor growth or tumor survival. These agents include interferons, which regulate cell gene expression, structure, and function; interleukin-2, which has several functions related to lymphoproliferation and mediation of lymphoid cell transport; anti-idiotype antibodies, which appear to cause a specific antiproliferative response against the patient's tumor; anti-idiotype vaccines, which produce cyclic complementary binding sites and idiotypes to induce specific immunity to tumors with resultant antitumor activity; radioisotope labeled monoclonal antibodies, which directly deliver tumoricidal doses of radiation to tumors, sparing normal tissue toxicity; and monoclonal antibody-immunotoxin conjugates, which directly deliver tumoricidal doses of radiation to tumors, sparing normal tissue toxicity. Encouraging results have been seen in clinical studies with these agents and much knowledge has been gained regarding the mechanisms involved. These findings dictate ongoing therapy modifications to produce continuing progress in the therapeutic applications of biologic agents in lymphoproliferative disease processes.

Bifunctional antibody: a binary radiopharmaceutical delivery system for imaging colorectal carcinoma.

In clinical studies we have evaluated a unique monoclonal antibody-based drug delivery system, a bifunctional antibody designed to deliver imaging or therapeutic agents, such as radioisotopes, drugs, or biologics, to tumor cells, while minimizing the dose to normal tissue. The bifunctional antibody, with one specificity to a tumor-associated antigen (carcinoembryonic antigen) and another specificity to a hapten, is injected and allowed to localize at a tumor site for 4 days. A hapten, tagged with a radioisotope, is subsequently injected for delivery to and capture by the prelocalized antibody at the tumor site. In studies reported here, the sulfhydryl groups of Fab' fragments of ZCE-025 and CHA-255 were linked with bis-maleimidomethyl ether to form an F(ab')2 bifunctional antibody coupled by a stable thioether linkage. EOTUBE, a hydroxyethylthiourido derivative of benzyl EDTA, was used as the hapten carrier of 111In. Fourteen patients 62-82 years old with recurrent or metastatic adenocarcinoma of the colon were studied. Twenty of 21 known lesions were imaged, and eight of nine new lesions were confirmed. With this fundamentally new approach to drug delivery, clearance from normal tissue is rapid, and high tumor:normal tissue ratios are expeditiously achieved.

Changes in leucocyte populations following murine bifunctional antibody infusion in colon cancer patients.

This study was undertaken to determine whether infusion of a unique ZCE/CHA bifunctional antibody (BFA, 5-40 mg) could alter the composition and functions of peripheral blood leucocytes in 18 patients with colon cancer. The BFA is made by combining chemically the Fab' fragments of two murine monoclonal antibodies. One fragment (ZCE 025) binds to the carcino-embryonic antigen (CEA) and the other (CHA 225) to an epitope, present on an 111In-benzyl EDTA analog of bleomycin (BLEDTA IV) and on 111In-hydroxy-ethyl-thiourea benzyl EDTA (EOTUBE). The radiolabelled epitope (111In-BLEDTA IV or 111In-EOTUBE) was given 4 days after prelocalization with BFA. Peripheral blood samples were tested before BFA infusion, at the end of infusion (1 h later), and at 4 and 7 days post-infusion. A 50% or greater suppression in lymphocyte responsiveness to phytohaemagglutinin (PHA) and concanavalin A (Con A) was seen in 13 out of 18 and 12 out of 18 subjects, respectively, at some time after BFA infusion; this was especially evident in those patients with pre-infusion stimulation indices of greater than 50 (PHA) and/or greater than 10 (Con A). In contrast, natural killer (NK) cell cytotoxicity and oxygen radical production increased in five out of 15 and in seven out of 18 subjects, respectively. Little or no change was observed in CD3, CD4, CD8, CD16, and CD19 markers on lymphocyte subpopulations as determined by flow cytometry. These data suggest that significant changes in mitogen-induced lymphoproliferation. NK cell cytotoxicity, and oxygen radical production can occur in a substantial proportion of cancer patients after infusion of the ZCE/CHA bifunctional antibody system. The immunomodulation was unrelated to initial BFA dose, dose of BFA as a carrier, or to subsequent infusion of either form of the 111In epitope. The clinical significance of these phenomena, if any, remains to be determined.

Hyperthermia enhances localization of 111In-labeled hapten to bifunctional antibody in human colon tumor xenografts.

A unique bifunctional antibody (BFA) delivery system was examined for radiolocalization and distribution following hyperthermia (41.5 degrees C, 45 min) of T380h human colon tumor xenografts. The BFA is an F(ab')2 fragment made by combining two murine monoclonal antibodies with different specificities, one directed against carcinoembryonic antigen (monoclonal antibody CEM 231) and the other (monoclonal antibody CHA 255) against a hapten found on a derivative of 111In-labeled benzyl-EDTA (EOTUBE). This BFA is known as CEM/CHA. The CEM/CHA accumulates in carcinoembryonic antigen-expressing tissue and clears from normal tissues prior to administration of the radiolabeled hapten. T380h tumor chunks were injected s.c. into 31 nude mice. Two weeks later mean tumor volume was 352 mm3 and the animals were assigned to one of four groups: (a) CEM/CHA + hyperthermia + 111In-EOTUBE; (b) CHA 255 F(ab')2 + hyperthermia + 111In-EOTUBE, and (c and d) treated in the same manner as a and b, respectively, but without heat. The CEM/CHA, CHA 255 F(ab')2, and 111In-labeled hapten were injected i.p. at 14 micrograms, 7 micrograms, and 140-200 microCi/mouse, respectively. The hyperthermia was administered 22-24 h after BFA and the radiolabeled hapten was injected 2 h later. Twenty-four h thereafter, the animals were euthanized for testing. A significantly greater percentage of injected radioactivity localized within heated compared to unheated tumors in mice given CEM/CHA and 111In-EOTUBE (7.39%/g tumor and 4.46%/tumor versus 2.72%/g tumor and 1.44%/tumor, respectively). The percentage of kidney activity in mice given CHA 255 F(ab')2 fragments and heat was 57% lower than in the nonheated group when expressed on a per g basis (12.73 and 22.20%, respectively). Microautoradiography showed greater radiolocalization in heated tumors than in nonheated control tumors of comparable size. Semiquantification by immunoperoxidase staining for carcinoembryonic antigen did not reveal similar differences in the amounts of antigen present in tumors from heated and nonheated groups. These findings suggest that hyperthermia could be used to enhance delivery of radiolabeled haptens to prelocalized BFA and, thus, to enhance tumor imaging and therapeutic efficacy.

Radiolocalization of human small cell lung cancer and antigen-positive normal tissues using monoclonal antibody LS2D617.

The murine monoclonal antibody LS2D617, which reacts with an antigen associated with human small cell lung carcinoma (SCLC), was tested in preclinical models to assess its potential for specific targeting of tumors in human SCLC cancer patients. LS2D617 detects a cell antigen on the surface of cultured SCLC and neuroblastoma cell lines. Scatchard analysis of the binding of LS2D617 to NCIH69 SCLC cells indicates an affinity constant of about 1 x 10(8) M-1 and an epitope expression level of approximately 2 x 10(6) antigenic sites/cell. Molecular weight analysis of the target antigen and antibody competition experiments showed that LS2D617 should be classified as a SCLC Cluster 1 antibody (i.e., reacts with the neural cell adhesion molecule). LS2D617 was labeled with 111In and tested for biodistribution (4, 24, 48, 72, and 96 h postinjection) in nude mice bearing the human SCLC NCIH69 tumor. Tumor values peaked at about 35% injected dose/g (Day 3) compared with about 8% injected dose/g for an irrelevant IgG1 antibody while normal tissue accumulation for both antibodies was about 2-8% injected dose/g. Immunohistochemical studies demonstrated that LS2D617 reacts with the central nervous system, peripheral nerves, endocrine tissues, and heart tissue of rabbits as it does in human tissues. The ability of LS2D617 to accumulate in vivo in normal tissues that express the specific target antigen was tested in rabbits. Rabbits given i.v. injections of 111In-LS2D617 or control labeled antibody were sacrificed at 48 h and tissues were examined by gamma well counting, autoradiography, and immunohistochemical staining for murine immunoglobulin. Specific uptake was seen in all sites defined as antigen positive by immunohistology (i.e., heart, liver bile duct, peripheral nerves, pituitary, adrenal), excepting the central nervous system (brain and spinal cord) which was inaccessible to antibody because of the blood brain barrier. The use of preclinical in vivo targeting models to assess tumor as well as antigen-positive normal tissue targeting should aid in the strategy of antibody-based therapeutic intervention of human cancer by providing insight into the potential for tumor targeting and normal tissue toxicity that may be encountered in the clinic.

Enhancement of immune status by high levels of dietary vitamin B-6 without growth inhibition of human malignant melanoma in athymic nude mice.

The effects of dietary vitamin B-6 supplementation on the development of human malignant melanoma (M21-HPB) xenografts and on in vitro responses of leukocytes were examined. Male athymic nude mice, five weeks old, were divided into two groups of 48 each and fed 20% casein diets containing pyridoxine (PN) at 4.1 (control diet) and 61.6 mg/kg diet for 10 weeks. After four weeks of dietary treatment, 20 animals from each dietary group were injected subcutaneously with 3 x 10(7) melanoma cells. After 4, 8, and 10 weeks of dietary regimen, animals from each group were killed and blood, liver, and spleen samples were obtained. Food consumption and mouse body weights were similar between groups, and no difference was noted in tumor incidence or volume. Noninjected and tumor-bearing mice given the PN 61.6 diet generally exhibited greater oxygen radical production by phagocytic cells from blood and spleen than did animals fed the PN 4.1 diet. Spleen and blood B lymphocyte proliferation in response to lipopolysaccharide (LPS) was enhanced (10 and 30%) in the noninjected animals given the PN 61.6 diet. In addition, tumor-bearing mice fed the PN 61.6 diet had significantly greater LPS-induced spleen cell proliferation at eight weeks when compared with mice consuming the PN 4.1 diet. Despite immune enhancement, tumor incidence and progression was not modified by a high level of dietary vitamin B-6. Therefore, it is tempting to speculate that tumor inhibition by high dietary vitamin B-6 may be mediated by T lymphocyte-dependent mechanisms that are lacking in these genetically immuno-deficient mice.

Effects of radiolabelled monoclonal antibody infusion on blood leukocytes in cancer patients.

This study was undertaken to investigate the effects of a single infusion of radiolabelled murine monoclonal antibody (MAb) on peripheral blood leukocytes in cancer patients. Eleven patients with disseminated colon cancer, malignant melanoma, or lung adenocarcinoma were infused with 111In-labelled anti-ZCE 025, anti-p97 type 96.5c, or LA 20207 MAb, respectively. Blood samples were obtained before infusion, immediately after infusion (1 hr), and at 4 and 7 days postinfusion. Flow cytometry analysis of CD3+, CD4+, CD8+, CD16+, and CD19+ lymphocytes showed increasing CD4:CD8 ratios in seven patients after infusion. This phenomenon was not restricted to antibody subclass or to type of cancer. Two of the remaining patients exhibited a marked post-infusion increase in CD8+ cells. In all three patients with malignant melanoma, decreasing levels of CD16+ lymphocytes were noted after infusion and natural killer cell cytotoxicity showed fluctuations which paralleled the changes in the CD16+ subpopulation. Oxygen radical production by phagocytic cells was markedly affected in three subjects. These results suggest that a single infusion of radiolabelled murine MAb may alter the balance of critical lymphocyte subpopulations and modulate other leukocyte responses in cancer patients.

Effects of monoclonal antibody, recombinant interferon-gamma, and tumor necrosis factor-alpha in the treatment of human melanoma xenografts.

ZME-018 monoclonal antibody (MAb, IgG2a subclass, 0.04 mg), recombinant human tumor necrosis factor-alpha (rHuTNF-alpha, 10(4) units), and recombinant human interferon-gamma (rHuIFN-gamma, 10(6) units) were injected intravenously into athymic nude mice bearing human malignant melanoma (Brown C5513) xenografts. Sixty-four animals were injected subcutaneously with 0.2 ml tumor chunks 4 days prior to administration of one or more of the treatments. The mice were randomized into eight groups so that mean tumor volume/group before initiation of treatment was similar (212-360 mm3); (a) saline, 2X; (b) rHuTNF-alpha, 1X; (c) rHuIFN-gamma, 1X; (d) ZME-018, 1X; (e) rHuIFN-gamma + rHuTNF-alpha, 1X each; (f) rHu-IFN-gamma + ZME-018 + rHuTNF-alpha, 1X each; (g) rHuTNF-alpha + ZME-018, 2X each; (h) rHuTNF-alpha + ZME-018, 3X each. The order of administration of the agents in those groups given more than one modality is as shown above and each injection was separated by a 24 h period. Tumor volume was measured daily for 9 days after the beginning of treatment. Compared to control mice, minimal suppression of tumor growth was noted when ZME-018, rHuTNF-alpha, or rHuIFN-gamma was used singly, but significantly (p less than or equal to 0.05) slower tumor progression occurred in animals given rHuIFN-gamma + rHuTNF-alpha or ZME-018 + rHuTNF-alpha when compared to controls. Histopathologic analyses of tumor biopsies obtained at 1 and 4 days after the last treatment for each group indicated that 15-95% necrosis was present. Necrosis was most striking in the animals given rHuIFN-gamma + rHuTNF-alpha or the ZME-018 MAb alone. However, the group receiving all three agents exhibited a tumor growth rate similar to that seen in the controls and demonstrated minimal necrosis. These results suggest that ZME-018, rHuIFN-gamma, and rHuTNF-alpha may be useful in the treatment of human melanoma. However, the effects of administration of all three of these agents in a single host needs to be evaluated further.

Evaluation of cancer patient leukocyte responses in the presence of physiologic and pharmacologic pyridoxine and pyridoxal levels.

Peripheral blood samples from six cancer patients (five colon cancer, one lung cancer) and six healthy volunteers were tested in vitro for oxygen radical production by phagocytic cells and in assays of mitogen-induced lymphoblastogenesis at physiologic and pharmacologic concentrations of pyridoxine (PN, 1.8-96 nmol/ml) or pyridoxal (PL, 0.08-90 nmol/ml). Plasma levels of pyridoxal-5'-phosphate (PLP), 4-pyridoxic acid (4PA), pyridoxamine phosphate (PMP), and PL were also determined. Phagocytic cells from three patients showed significantly increased capacity for oxygen radical production when incubated in PL-, but not PN-supplemented media. Oxygen burst capacity of cells from healthy subjects was significantly enhanced by PN-, but not PL-enriched media. Lymphocyte responsiveness to phytohemagglutinin or pokeweed mitogen (PWM) stimulation showed a modest increase in cell activation in three patients as the concentration of PN was increased; with concanavalin A, two showed enhanced responsiveness. On the other hand, PL-supplementation resulted in greater cell proliferation only with PWM. The cancer patients had significantly lower plasma PLP, 4PA, and PMP levels when compared with the healthy volunteers. These data indicate that in the cancer patients and in a majority of the healthy volunteers, vitamin B-6 status was marginal or deficient and suggest that increasing PN or PL in vivo levels may augment functions related to cell-mediated immunity.

Effect of pyridoxine and pyridoxal on the in vitro growth of human malignant melanoma.

The in vitro effect of vitamin B-6 supplementation on the growth of a human malignant melanoma cell line (M21-HPB) was investigated. Varying concentrations of pyridoxine (PN) or pyridoxal (PL) were added to cell cultures and incubated for 12 days. Pharmacologic levels of PL (0.25-0.5 mM) resulted in significant reductions in cell proliferation. Physiologic levels (0.005 mM) did not retard growth. Cells incubated with PN showed growth stimulation. Intracellular levels of PL and pyridoxal 5'-phosphate (PLP) were increased in cells exposed to pharmacologic PL (0.05-0.5 mM) concentrations, but not PN. These data suggest that PL or PLP may be involved in regulating the growth of melanoma cells and that vitamin B-6 may have potential use as an antineoplastic agent.

Suppression of tumor growth and enhancement of immune status with high levels of dietary vitamin B6 in BALB/c mice.

Effects of dietary vitamin B6 at levels ranging from deficiency to megadoses on the development of herpes simplex virus type 2-transformed (H238) cell-induced tumors and on in vitro responses relating to cell-mediated immunity were examined. Male BALB/cByJ mice (n = 260), 5 weeks of age, were fed 20% casein diets containing pyridoxine (PN) at 0.2, 1.2 for the control diet, 7.7, or 74.3 mg/kg diet for 4-11 weeks. After 4 weeks of dietary treatment, 120 of the mice received an injection of H238 cells; mice without H238 injection served as controls. At 4, 8, and 11 weeks, animals from each group were euthanized and blood and spleen samples obtained. Mice fed 0.2 mg PN developed mild deficiency symptoms and gained significantly less weight than those fed 1.2-, 7.7-, and 74.3-mg PN diets. Thirteen to 16 days after tumor cell injection, primary tumor incidence was lowest in mice fed 74.3 mg PN; later, incidence among groups was similar. Mice fed 1.2 mg PN had the largest primary tumor volume, the highest incidence of lung metastases, and the greatest number of metastatic nodules per animal at 7 weeks post injection. Overall, lower tumor volumes were found in animals fed 7.7 and 74.3 mg PN (14 and 32% less than the tumor volume for those fed 1.2 mg PN, respectively); mice fed 0.2 mg PN had the lowest tumor volume. Blood and spleen lymphoproliferative response to stimulation by phytohemagglutinin or concanavalin A generally tended to be higher in mice fed 7.7 and 74.3 mg PN as compared to that in animals fed either 0.2 or 1.2 mg PN. However, decreased mitogen-stimulated responsiveness was observed in all animals with progressive tumor growth. Tumor growth also resulted in splenomegaly and increased thymic atrophy. Significant negative relationships between tumor volume and tumor pyridoxal 5-phosphate (PLP) concentrations were observed for 1.2-, 7.7-, and 74.3-mg PN diet groups. These data suggest that high dietary intake of vitamin B6 may have suppressed tumor development by either immune enhancement or PLP growth regulation of this tumor.

Enhancement of monoclonal antibody binding to melanoma with single dose radiation or hyperthermia.

We undertook this study to determine whether radiation (10 Gray, single dose) or water bath hyperthermia (41 degrees C, 45 min) could enhance binding of 111In-labeled anti-p97a monoclonal antibody (MAb) to human melanoma tumors transplanted subcutaneously into nude mice. Sixty animals were given injections of 1-2 X 10(7) Brown C5513 melanoma cells. At 1-2 weeks postinjection, two-thirds of the mice were treated (one-third served as controls). Within 3 hours after treatment, each animal was given iv 2 muCi 111In-anti-p97a MAb. At 24 and 48 hours thereafter, whole-body scans were done with the use of a MaxiCamera 300 A/M unit, and the ratio of activity at the tumor and liver was determined. Some animals were kept for 7 days posttreatment, whereas others were taken after the 48-hour scan for determination of biodistribution of the radiolabeled complex. Enhancement of MAb binding was demonstrated by either modality, although enhancement was more consistent with radiation. The therapeutic efficacy of MAb may be enhanced with increased binding of radioactive MAb complexes through single dose radiation or hyperthermia.

Lipid-soluble inhibitors of dihydrofolate reductase. I. Kinetics, tissue distribution, and extent of metabolism of pyrimethamine, metoprine, and etoprine in the rat, dog, and man.

With the aim of developing anticancer compounds which overcome some of the clinical limitations of the polar dihydrofolate reductase inhibitor, methotrexate, the physicochemical properties, kinetics, and metabolism of a series of lipid-soluble 2,4-diamino-5-phenylpyrimidine folate antagonists have been studied. Metoprine and etoprine, potent inhibitors of mammalian dihydrofolate reductase, were compared with pyrimethamine, a widely used antimalarial drug. The development of assay procedures in our laboratory and the synthesis of radiolabeled compounds have enabled a comparison of the kinetic characteristics and tissue distribution of these compounds in several species. The relative lipophilicities as indicated by the octanol/water partition coefficient are: etoprine (log P = 3.19) greater than metoprine (log P = 2.82) greater than pyrimethamine (log P = 2.69). Etoprine has the greatest affinity for plasma proteins, but all three compounds are bound to human plasma protein by 87% or more at therapeutic concentrations. Pharmacokinetic studies in the mouse, rat, dog, and man indicate that metoprine has the longest plasma half-life in all four species. The mean plasma half-lives in man are: pyrimethamine, 85 hr; metoprine, 216 hr; etoprine, 176 hr.